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In This Issue……

All Providers:

• CPT Code Update 2003
• CPT Codes Covered for Dates of Service on or After January 1, 2002
• General Medicaid Billing Seminars
• Medicaid Coverage for Pregnancy-Related Services
• Proposed Medical Coverage Policies

Adult Care Home Providers:

• Directions to the Adult Care Home Mental Health Needs Assessment Seminar
• Mental Health Needs Assessment Project

Anesthesiologists:

• Change in Carolina ACCESS Editing for Anesthesiology, Pathology or Radiology Services

Area Mental Health Centers:

• Billing Changes for CAP-MR/DD Services
• Correction to V Code Diagnosis for Outpatient Occupational Therapy Services
• Respiratory Therapy Criteria
• Seminars for HIPAA Code Conversions for Services Provided to Children under the Age of 21

CAP-MR/DD Case Managers and Providers:

• Billing Changes for CAP-MR/DD Services

Carolina ACCESS Primary Care Providers:

• Carolina ACCESS Enrollment, Referral, Emergency Room, and Utilization Reports
• Change in Carolina ACCESS Editing for Anesthesiology, Pathology or Radiology Services
• Referral Policy for Specialty Care

Dental Providers:

• ADA Code Updates for the Year 2003 and the New Dental Claim Form

Developmental Evaluation Centers:

• Correction to V Code Diagnosis for Outpatient Occupational Therapy Services
• Respiratory Therapy Criteria

Durable Medical Equipment Providers:

• HCPCS Code Changes
• Length of Need Documentation
• Removal of Codes E1405 and E1406
• Use of Modifiers for Durable Medical Equipment Claims

Head Start Programs:

• Respiratory Therapy Criteria

Health Department Dental Clinics:

• ADA Code Updates for the Year 2003 and the New Dental Claim Form

Health Departments:

• Correction to V Code Diagnosis for Outpatient Occupational Therapy Services
• Respiratory Therapy Criteria

Hearing Aid Providers:

• HIPAA Code Conversion for the Hearing Aid Program

Home Health Agencies:

• Deletion of Skilled Nursing HCPCS Codes W9952 through W9959
• Denials Due to Incorrect Billing Procedure
• Respiratory Therapy Criteria

Home Infusion Therapy Providers:

• Billing Changes for Home Infusion Drug Therapies

Hospital Outpatient Clinics:

• Respiratory Therapy Criteria

Hospitals:

• Denials Due to Incorrect Billing Procedure

Independent Practitioners:

• Correction to V Code Diagnosis for Outpatient Occupational Therapy Services
• Respiratory Therapy Criteria

Local Education Agencies:

• Respiratory Therapy Criteria

Optical Providers:

• HIPAA Code Conversion for the Visual Services Program

Pathologists:

• Change in Carolina ACCESS Editing for Anesthesiology, Pathology or Radiology Services

Personal Care Services Providers:

• Billing and Claim Form Changes for Personal Care Services in Private Residences

Physicians:

• Correction to V Code Diagnosis for Outpatient Occupational Therapy Services
• Respiratory Therapy Criteria

Private Duty Nursing Providers:

• Billing Changes for Private Duty Nursing

Radiologists:

• Change in Carolina ACCESS Editing for Anesthesiology, Pathology or Radiology Services

Residential Treatment Providers:

• Seminars for HIPAA Code Conversions for Services Provided to Children under the Age of 21

Attention: All Providers

Proposed Medical Coverage Policies

In accordance with Session Law 2001-424, Senate Bill 1005, proposed new or amended Medicaid medical coverage policies are available for review and comment on DMA’s website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.

Darlene Creech
Medical Policy Section
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511

The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.

Darlene Creech, Medical Policy Section
DMA, 919-857-4020

Attention: All Providers

Medicaid Coverage for Pregnancy-Related Services

Pregnant women may receive Medicaid under the Medicaid for Pregnant Women (MPW) program or under other Medicaid programs, such as Medicaid for Families (MAF), Medicaid for the Disabled (MAD), Work First (AAF), etc. Under the MPW program, the pregnant woman receives a pink Medicaid identification card. Medicaid coverage under this category is limited to pregnancy-related services and other conditions that may complicate the pregnancy.

Under the other Medicaid programs, the pregnant woman receives a blue Medicaid identification card. These women may receive coverage for all Medicaid covered services including pregnancy-related services, prescriptions, dental, and vision care. Pregnancy-related services are exempt from the 24-visit limit, the six-prescription limit, and from copayment deductions.

Andy Wilson, Recipient and Provider Services
DMA, 919-857-4019

Attention: All Providers

CPT Code Update 2003

The Division of Medical Assistance has completed the coverage determination review of the new codes published in the Current Procedural Terminology CPT 2003. The table below indicates the new codes that will be covered by the N.C. Medicaid program. Unlisted procedure codes will be reviewed on a case-by-case basis following established billing guidelines. Notification will be made through a future general Medicaid bulletin when the system is ready to accept new claims and when denied claims may be resubmitted. Notification will be posted on DMA’s website if the system is ready prior to an upcoming bulletin publication.

20612	21046	21047	21048	21049	29827	29873	29899	33215	33224
33225	33226	33508	34833	34834	34900	35572	36511	36512	36513
35614	36515	36516	36536	36537	37182	37183	37500	38205	38206
38242	43201	43236	44206	44207	44208	44210	44211	44212	44238
44701	45335	45340	45381	45386	46706	49419	49904	50542	50543
50562	51701	51702	51703	55866	56820	56821	57420	57421	57455
57456	57461	58146	58290	58291	58292	58293	58294	58545	58546
58552	58553	58554	61316	61322	61323	61517	61623	62148	62160
62161	62162	62163	62164	62165	62264	64416	64446	64447	64448
66990	75901	75902	75954	76071	76801	76802	76811	76812	76817
83880	84302	85004	85032	85049	85380	87255	87267	87271	88174
88175	89055	92601	92602	92603	92604	92607	92608	92609	92610
92611	92612	92614	92616	92700	93580	93581	95990	96920	96921
96922	99293	99294	99299

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

CPT Codes Covered for Dates of Service on or After January 1, 2002

The table below indicates the additional new Current Procedure Terminology (CPT) codes that are covered by the N.C. Medicaid program effective with date of service January 1, 2002:

Claim Filing Instructions

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

General Medicaid Billing Seminars

Seminars on general Medicaid billing guidelines are scheduled for September 2003. Registration information and a list of dates and site locations for the seminars will be published in the August 2003 general Medicaid bulletin.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Adult Care Home Providers

Mental Health Needs Assessment Project

The Department of Health and Human Services has been charged with the development and implementation of a Mental Health Needs Assessment Project for Adult Care Homes. This comprehensive effort is designed to conduct assessments of all Medicaid-eligible recipients who reside in adult care homes to determine those who need mental health services and the level of services needed. The Division of Medical Assistance is the lead agency for this project.

Seminars focusing on how to complete the mental health assessment forms are scheduled for July 22, 23, and 24 at the locations listed below. Preregistration for the seminars is required. Providers may register for the Adult Care Homes Mental Health Needs Assessment seminars by completing and submitting the Adult Care Homes Mental Health Needs Assessment Seminar Registration Form or through Online Registration. Registration forms must be submitted by 5:00 p.m. July 18, 2003.

Due to limited seating, registration is limited to two staff members per office. Seminars begin at 9:00 a.m. and end at 12 noon. Providers are encouraged to arrive by 8:45 a.m. to complete registration. Three Continuing Education Units (CEU) will be offered to those who attend the entire seminar.

• Directions to the Seminars

Bill Hottel, Adult Care Home Unit
DMA, 919-857-4020

Directions to the Adult Care Home Mental Health Needs Assessment Seminar

A-B Technical College, Simpson Lecture Room #109, Simpson Building – Asheville, North Carolina
Directions to the College
Take I-40 to exit 50. Travel north on Hendersonville Road, which turns into Biltmore Avenue. Continue on Biltmore Avenue toward Memorial Mission Hospital. Turn left onto Victoria Road.

Campus
Stay on Victoria Road. Turn right between the Holly Building and the Simpson Building. The Simpson Building is located on the right.

Martin Community College, Main Conference Room – Williamston, North Carolina
Take Highway 64 into Williamston. Martin Community College is located approximately 1 to 2 miles west of Williamston. The main conference room is located in Building 2.

Wake County Commons Building – Raleigh, North Carolina
Take the I-440 Beltline east to the exit 15, Poole Road. Turn right onto Poole Road. Travel approximately ½ mile. Turn left into the Wake County Office Park. Follow the winding road to the bottom of the hill; there are small directional signs along the way. The Commons Building is identified by the tall flag pole in front of the building. It is next to the last building in the office park. Parking is available across the street or to the left of the facility.

Attention: Area Mental Health Centers and CAP-MR/DD Case Managers and Providers

Billing Changes for CAP-MR/DD Services

Effective with date of service September 30, 2003, the N.C. Medicaid program will end-date state-created procedure codes used to bill services provided through the Community Alternatives Program for Persons with Mental Retardation and Developmental Disabilities (CAP-MR/DD). Effective with date of service October 1, 2003, national codes for these services will be implemented to comply with the Health Insurance Portability and Accountability Act (HIPAA).

State-created code W8164, Augmentative Communication Device, Rental, will not be replaced.

The maximum reimbursement rate will not change for the following codes, except where noted.

1. State-created codes W8119 and W8200 will be replaced with national code S5150. There will not be a differentiation between community-based (W8119) and facility-based (W8200).
2. Identify the product in "Remarks."
3. National modifier "HQ" identifies a group setting.
4. National modifier "TD" identifies that an RN provides the service and "TE" identifies that an LPN provides the service.
5. National modifier "HI" identifies an integrated mental health and mental retardation/developmental disabilities program.
6. National modifier "HQ" identifies a group setting. A rate adjustment is required for this code. The new rate will be published in a future general Medicaid bulletin.

The code conversion requires the use of some national codes with descriptions that may imply a change in coverage. However, there are no changes to the current CAP-MR/DD coverage policy, service definitions or requirements, except as noted. Providers must be alert to the use of the national code as it applies to CAP-MR/DD. (Refer to the Division of Mental Health, Developmental Disability, and Substance Abuse Services's website for service information.)

Because there are several new national codes that are used for multiple CAP programs as well as regular Medicaid services, the Division of Medical Assistance will identify CAP recipients as members of a "population group" for their specific CAP program. This is required to control and monitor billing for services. Please refer to upcoming general Medicaid bulletins for information on the implementation of CAP population group designations.

Division of Mental Health, Developmental Disabilities, and Substance Abuse

Diane Holder, R.N., Behavioral Health Care, Medical Policy Services
DMA, 919-857-4020

Attention: Area Mental Health Programs and Residential Treatment Providers

Seminars for HIPAA Code Conversions for Services Provided to Children under the Age of 21

Seminars for area mental health programs and residential treatment providers are scheduled for September 2003. The seminars will provide information on the conversion to CPT codes for services provided to children under the age of 21. Registration information and a list of dates and site locations for the seminars will be published in the August 2003 general Medicaid bulletin.

Carol Robertson, Behavioral Health Services
DMA, 919-857-4020

Attention: Area Mental Health Centers, Developmental Evaluation Centers, Independent Practitioners, Local Health Departments, and Physician Services

Correction to V Code Diagnosis for Outpatient Occupational Therapy Services

The May 2003 bulletin article titled Addition of V Code Diagnosis for Outpatient Specialized Therapies stated that all occupational therapy claims, including claim adjustments and resubmitted claims, submitted for billing June 1, 2003 or after, must include the discipline-specific ICD-9-CM diagnosis code V57.2. In order to meet HIPAA requirements, the code has been corrected to V57.21. Effective July 1, 2003, use diagnosis code V57.21. Claims previously submitted for processing using diagnosis code V57.2 do not need to be corrected and resubmitted.

This does not change the requirement to bill the primary diagnosis that justifies the need for the specialized therapy. Remember: The primary treatment ICD–9-CM diagnosis code must be entered first on the claim form. The discipline-specific V code should follow the primary treatment code.

Nora Poisella, Medical Policy Section
DMA, 919-857-4020

Attention: Area Mental Health Centers, Developmental Evaluation Centers, Independent Practitioners, Physician Services, Local Health Departments, Home Health Agencies, Hospital Outpatient Clinics, Head Start Programs, and Local Education Agencies

Respiratory Therapy Criteria

Medical Coverage Policy 8F, Outpatient Specialized Therapies, and 8G, Independent Practitioners, have been updated to include medical necessity criteria and prior approval criteria for continued treatment for respiratory therapy.

• Medical coverage policy 8F, Outpatient Specialized Therapies
• Medical coverage policy 8G, Independent Practitioners

Nora Poisella, Medical Policy Section
DMA, 919-857-4020

Attention: Carolina ACCESS Primary Care Providers

Carolina ACCESS Enrollment, Referral, Emergency Room, and Utilization Reports

The Division of Medical Assistance’s Managed Care Section is beginning the process of replacing paper copies of the Carolina ACCESS Enrollment, Referral, Emergency Room, and Quarterly Utilization reports with web-based versions of the reports. The target implementation date is December 2003. This article is the first in a series of articles to prepare primary care providers (PCPs) for this change and to provide instructions for accessing the web-based reports.

Internet access and minimum system requirements are necessary to access web-based reports. Providers who do not have Internet access or have systems that do not meet the minimum hardware and software requirements listed below, should begin immediately to upgrade their systems in preparation for the change.

In addition to system requirements, security access is required. Providers will be notified in upcoming Medicaid bulletins about how to obtain necessary security and how to contact customer support.

Access Points and Requirements
Internet ACCESS Required:

• PC must be connected to or capable of connecting to the Internet.
• If PC is behind a Firewall, Ports 80 and 443 must be open.

System Requirements
Minimum Hardware Specification for the PC Workstation:

• 200 MHz
• 2.1GB Hard Drive
• 3 ½" Floppy Drive
• CD Rom Drive
• 64MB Ram
• MS Mouse
• Monitor
• MS Keyboard
• Network Surge Protector

Minimum Software Requirements:

• Windows NT/Windows 2000 Operating System: NT 4.0 sp5 and above.
• Windows 9x Operating System: Windows 95 and above.
• Windows XP Operating System.
• Microsoft Internet Explorer (IE) version: Vs 5.5 sp2 and above with 128bit encryption.
• Netscape Navigator 6.0 or higher.

• Settings for Microsoft IE (Tools…Internet Options)
  Maximum of Medium Security.
  Allow per session cookies.
  Check for newer versions of stored pages set to: every time you visit the page.

The workstation must also have an appropriate viewer for a commonly published file format. Examples include:

• ASCII text reports
• Mainframe spool files
• Microsoft Office 97, 2000, or XP products: Word, Excel, and PowerPoint
• Adobe Portable Document Format (PDF), PostScript
• Crystal Decisions’ Crystal Reports
• HTML documents
• PCL reports

Managed Care Section
DMA, 919-857-4022

Attention: Carolina ACCESS Primary Care Providers, Anesthesiologists, Pathologists, and Radiologists

Change in Carolina ACCESS Editing for Anesthesiology, Pathology or Radiology Services

Effective September 1, 2003, Carolina ACCESS editing will be modified to allow payment for anesthesiology, pathology or radiology services that have not been authorized by the primary care provider if either the group provider number or the attending provider number billing the service identifies the provider as an anesthesiologist, pathologist or radiologist. Prior to September 1, 2003, unauthorized services billed by these disciplines will pay only if the billing provider number is identified as an anesthesiologist, pathologist or radiologist.

Managed Care Section
DMA, 919-857-4022

Attention: Carolina ACCESS Primary Care Providers

Referral Policy for Specialty Care

The Carolina ACCESS (CA) contract requires primary care providers (PCPs) to coordinate care for their enrollees by arranging referrals for medically necessary health care services that they do not directly provide. Although referrals are at the discretion of the PCP, requests for Medicaid covered specialty care must be based on the PCP’s assessment of the patient’s medical need. Medicaid covered services include medically necessary care by neurologists, cardiologists, infectious disease specialists, etc., as well as services rendered by chiropractors and podiatrists.

Referrals can be made by phone or in writing. When referring CA enrollees for specialty care, the PCP must define the scope of the referral. This includes the number of visits being authorized and the diagnostic evaluation needed to effectively evaluate the patient. To facilitate continuity of care for CA enrollees, any further diagnosis, evaluation or treatment of the patient not identified in the original referral is the responsibility of the PCP.

It is the responsibility of the specialty provider to obtain the PCP’s authorization (Carolina ACCESS provider number) prior to treatment. The PCP may refuse to authorize services if authorization is requested after the services have been rendered. This will result in denied claims.

The PCP may make referrals or authorize payment for services for their CA enrollees who have not contacted them for the purpose of establishing a patient/provider relationship.

PCPs must document all referrals in the patient’s medical record. The Division of Medical Assistance (DMA) provides a monthly referral report to each PCP for verification of the validity and accuracy of the referrals. Any inappropriate referrals should be reported to the PCP’s Managed Care Consultant for investigation.

Note: In addition to PCP referral authorization, prior approval (PA) may be required to verify medical necessity before rendering some services. Obtaining PA does not guarantee payment or ensure that the enrollee is eligible on the date of service.

Managed Care Section
DMA, 919-857-4022

Attention: Durable Medical Equipment Providers

Use of Modifiers for Durable Medical Equipment Claims

Effective with claims received August 1, 2003, durable medical equipment (DME) providers must use the following modifiers with HCPCS codes in block 24D when submitting DME claims:

NU for new purchase
UE for used purchase
RR for rental

These modifiers are used on the CMS-1500 claim form to replace type of service codes: N for new purchase, U for used purchase, and E for rental.

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020

Attention: Durable Medical Equipment Providers

HCPCS Code Changes

The following HCPCS codes are end-dated and replaced with new codes effective with date of service July 1, 2003. These changes are being made to comply with the implementation of national standard codes mandated by the Health Insurance Portability and Accountability Act (HIPAA).

These new codes do not require prior approval. However, as with all durable medical equipment, a Certificate of Medical Necessity and Prior Approval form must be completed.

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020

Attention: Durable Medical Equipment Providers

Length of Need Documentation

The prescribing physician, physician assistant or nurse practitioner must document on the Certificate of Medical Necessity and Prior Approval form the length of need for all items listed in the Capped Rental category of the Durable Medical Equipment Fee Schedule. Refer to Medical Coverage Policy 5, Durable Medical Equipment for additional information.

• DME Fee Schedule
• Medical coverage policy 5, Durable Medical Equipment

EDS, 1-800-688-6696 or 919-851-8888

Attention: Durable Medical Equipment Providers

Removal of Codes E1405 and E1406 from DME Fee Schedule

Effective July 1, 2003, HCPCS code E1405, oxygen and water vapor enriching system with heated delivery, and HCPCS code E1406, oxygen and water vapor enriching system without heated delivery, have been end-dated and removed from the Durable Medical Equipment Fee Schedule.

DME Fee Schedule

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020

Attention: All Dental Providers and Health Department Dental Clinics

ADA Code Updates for the Year 2003 and the New Dental Claim Form

In January 2003, the American Dental Association (ADA) revised the ADA claim form and the Current Dental Terminology (CDT-4) Users manual. The Division of Medical Assistance (DMA) and EDS are currently implementing system changes to comply with the new codes and claim form. The anticipated implementation date for the new form and procedure codes is October 1, 2003. However, providers should continue to use the 2000 ADA claim form and CDT-3 procedure codes until the final implementation date is confirmed.

Specific updates to CDT-4, including procedure code deletions, additions, and revised code descriptions, were published in the May 2003 general Medicaid bulletin. Upcoming Medicaid bulletins will specify the exact implementation date for the 2002 ADA claim form and procedure codes.

Once the system has been updated to accept the 2002 ADA claim form, providers will be given a three-month transition period to begin using the new form. During the transition period, both the 2000 and 2002 ADA claim form will be accepted.

Claim forms can be ordered from the ADA at the address listed below:

American Dental Association
Attn: Salable Materials Office
211 E. Chicago Avenue
Chicago, IL 60611
Telephone: 1-800-947-4746

ADA Procedure Codes Must be Billed with the "D" Prefix
Effective with dates of service beginning October 1, 2003, all dental procedures codes must be billed with the "D" prefix (such as D0120, D0150, etc.) for both electronic and paper claims. Services billed using the numeric zero prefix procedure codes will deny with the explanation of benefit (EOB) message 0024, which states: "Procedure code, procedure/modifier combination or revenue code is missing, invalid, or invalid for this bill type. Correct and rebill denied detail as a new claim."

ADA Code Updates for the Year 2003 and the New Dental Claim Form (May 2003 Medicaid Bulletin)

EDS, 1-800-688-6696 or 919-851-8888

Attention: Hearing Aid Providers

HIPAA Code Conversion for the Hearing Aid Program

To comply with the implementation of national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA), it is necessary to end-date all N.C. Medicaid state-created (local) codes and convert them to national codes. Effective with date of service July 31, 2003, all local hearing aid codes will be end-dated. Effective with date of service August 1, 2003, providers must submit national codes when billing for hearing aid services. These changes apply to paper and electronic claim formats. Please continue to use the CMS-1500 claim form (formerly HCFA-1500).

Hearing Aid/Device

Dispensing Fees

Note: V5241 cannot be billed if a dispensing fee is paid to the provider by the manufacturer.

Bill V5299 for dispensing earmolds (V5264) and/or accessories (V5267).

EDS, 1-800-688-6696 or 919-851-8888

Attention: Home Health Agencies

Deletion of Skilled Nursing HCPCS Codes W9952 through W9959

Effective with date of service October 1, 2003, home health providers will no longer use HCPCS codes to bill for home health skilled nursing visits. Providers must continue to follow the MEDICARE-Medicaid Skilled Services Billing Guide in Section 5, Home Health Services of the N.C. Medicaid Community Care Manual and use revenue codes 550 and/or 559 to bill for skilled nursing visits. The following HCPCS codes will be end-dated with date of service September 30, 2003.

• N.C. Medicaid Community Care Manual

Dot Ling, Medical Policy Section
DMA, 919-857-4021

Attention: Home Health Agencies and Hospital Providers

Denials Due to Incorrect Billing Procedure

Claims for home health services and outpatient services that are filed with the same revenue code on the same date of service on multiple details are being denied as duplicates. Providers must enter a separate detail line for each date of service, combining all units provided on that date in the detail. For example, if two billable home health skilled nursing visits are provided on the same day, the number of service units entered for that detail line is 2.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Home Infusion Therapy Providers

Billing Changes for Home Infusion Drug Therapies

Effective with date of service October 1, 2003, Home Infusion Therapy (HIT) providers must use national codes to bill for each drug therapy. The Division of Medical Assistance (DMA) must make these changes to comply with the implementation of the national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA). Providers should carefully note all of the changes involved in this conversion to the new codes. Please note that concurrent therapy codes now have modifiers that describe when a therapy is a second concurrently administered infusion therapy (SH) and when a therapy is a third or more concurrently administered infusion therapy (SJ). The key points include:

• The code conversion requires the use of some national codes with descriptions that may imply a change in coverage. However, there are no changes to the HIT coverage policy in Section 7, Home Infusion Therapy of the N.C. Medicaid Community Care Manual. Providers must be alert to the use of the national code as it applies to N.C. Medicaid.
• The new codes separate the nursing services from the HIT drug therapy package. There is a separate per diem code for nursing services that must be entered on the claim after the HIT drug therapy code.
• When billing for a combination of therapies, providers must enter the code for each of the therapies, plus the code for the nursing services. DMA has designated which therapy is billed as the second and as the third therapy in a combination therapy. The designations are for billing purposes only. They are not intended to have any clinical implications. The second and third therapies are identified with a modifier that must be included on the claim.
• Codes must be entered in a specific order on the claim form as outlined under Billing Instructions.
• All of the HIT drug therapies will continue to be paid as a per diem. The combined fees for the separate new codes for therapies and for the nursing services equal the current fees.

End-Dated Codes
Effective with dates of service September 30, 2003, the following codes are end-dated:

New Codes
Effective with date of service October 1, 2003, HIT providers must use the following codes to bill for drug therapies. The national code description is listed with any requirements specific to N.C. Medicaid shown in brackets at the end of the description. Please see Billing Instructions for the required code combinations.

Code	Description	Maximum Reimbursement Rate
S9494	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drug and nursing visits coded separately), per diem [For N.C. Medicaid, this code may be used for only antibiotic therapy.]	$ 58.33
S9329	Home infusion therapy, chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drug and nursing visits coded separately), per diem	53.15
S9325	Home infusion therapy, pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, (drug and nursing visits coded separately), per diem	44.47
T1030	Nursing care, in the home, by registered nurse, per diem	40.18
S9494SH	Antibiotic therapy, per diem [National modifier SH denotes the second concurrently administered infusion therapy.]	40.90
S9329SH	Chemotherapy, per diem [National modifier SH denotes the second concurrently administered infusion therapy.]	52.96
S9325SH	Pain management therapy, per diem [National modifier SH denotes the second concurrently administered infusion therapy.]	47.73
S9325SJ	Pain management therapy, per diem [National modifier SJ denotes the third concurrently administered infusion therapy.]	48.38
S9379	Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drug and nursing visits coded separately), per diem [For N.C. Medicaid, this code may be used for only the termination allowance for HIT drug therapies.]	38.26
T1002SD	RN Services, up to 15 minutes [National modifier SD denotes that the service was provided by a registered nurse with specialized, highly technical home infusion training.] [For N.C. Medicaid, this code may be used for only RN Monitoring (over 2 hours) for Amphotericin B infusion therapy.]	$ 6.70

Billing Instructions
The following instructions amend the instructions in subsection 7.10.4, Filing a Claim in the N.C. Medicaid Community Care Manual in regard to the completion of block 24 on the CMS-1500 for drug therapies.

The new codes require a provider to enter multiple detail lines when billing for a course of treatment. The code combinations are listed below:

When billing for…	Use these codes…
Antibiotic Therapy	S9494 - Home infusion therapy, antibiotic and T1030 - Nursing care, in the home, by registered nurse, per diem
Chemotherapy	S9329 - Home infusion therapy, chemotherapy infusion and T1030 - Nursing care, in the home, by registered nurse, per diem
Pain Management Therapy	S9325 - Home infusion therapy, pain management infusion and T1030 - Nursing care, in the home, by registered nurse, per diem
Two Simultaneous Antibiotic Therapies	S9494 - Home infusion therapy, antibiotic and S9494SH - Antibiotic therapy as the second billed therapy and T1030 - Nursing care, in the home, by registered nurse, per diem
Antibiotic and Chemotherapy	S9494 - Home infusion therapy, antibiotic and S9329SH - Chemotherapy as the second billed therapy and T1030 - Nursing care, in the home, by registered nurse, per diem
Antibiotic and Pain Management	S9494 - Home infusion therapy, antibiotic and S9325SH - Pain management infusion as the second billed therapy and T1030 - Nursing care, in the home, by registered nurse, per diem
Chemotherapy and Pain Management	S9329 - Home infusion therapy, chemotherapy and S9325SH - Pain management infusion as the second billed therapy and T1030 - Nursing care, in the home, by registered nurse, per diem
Antibiotic, Chemotherapy, and Pain Management	S9494 - Home infusion therapy, antibiotic and S9329SH - Chemotherapy as the second billed therapy and S9325SJ - Pain management infusion as the third billed therapy and T1030 - Nursing care, in the home, by registered nurse, per diem

In addition, certain codes must be billed in a specific order.

1. Always bill the primary therapy code (S9494, S9329 or S9325) first.
2. Bill nursing services (T1030) after the related primary therapy code. Nursing services will not be paid unless the related primary therapy code has been paid for the same date of service.
3. If billing a combination of two therapies, bill the second concurrent therapy after the related primary therapy code. The second therapy will not be paid unless the appropriate primary therapy code has been paid for the same date of service.
4. If billing the combination of antibiotic, chemotherapy, and pain management, bill pain management as the third concurrent therapy (S9325SJ) after billing for chemotherapy as the second concurrent therapy (S9329SH). Pain management as a third therapy will not be paid unless S9329SH has been paid for the same date of service.
5. When billing the termination allowance (S9379), bill the allowance after the related primary therapy code. The termination allowance will not be paid unless one of the therapy codes has been paid for a corresponding date of service.
6. When billing the RN monitoring for Amphotericin B (TD1002SD), bill for the monitoring after the antibiotic therapy (S9494).

Example: A provider wishes to bill for a concurrent course of treatment that includes antibiotic therapy and pain management therapy that was ordered for 10/15 through 10/21. The physician terminates the treatment on 10/19. The provider intends to bill for the combination therapy for 10/15 through 10/19. Because the treatment was terminated on 10/19 with two days remaining in the original prescribed course of treatment, the provider also wishes to bill for two days of the termination allowance. The provider will enter a detail line for S9494 antibiotic therapy on the claim. After entering the detail line for S9494, the provider will enter the detail lines for the following services (they may be entered in any sequence):

• S9325SH for pain management therapy as the second therapy;
• T1030 for nursing care, in the home, by registered nurse, per diem; and
• S9379 for the termination allowance.

The provider must complete each detail line in block 24 on the CMS-1500 as follows:

24A. DATE(S) OF SERVICE, From/To:

Drug Therapy Codes: Enter the date for the month that the course of treatment begins in the From block. If the treatment is continued from the prior month, enter the first day of the month in the From block. Enter the last day of the course of treatment for the month in the To block. If the treatment extends into the following month, enter the last day of the month in the To block. Do NOT span calendar months. Do NOT include dates of service prior to October 1, 2003.

Example: The patient's course of treatment is from 10/25/03 through 11/15/03. On the claim submitted for October, enter 102503 in the From block and 103103 in the To block. On the claim submitted for November, enter 110103 in the From block and 111503 in the To block.

When billing for a second therapy, the dates of service must be the same as the primary therapy. When billing for a third therapy, the dates of service must be the same as the primary and second therapy.

Nursing Services: Enter the same dates of service as listed for the related drug therapy.

RN Monitoring for Amphotericin B: Use a separate line for each day the monitoring is done. Enter the date of the monitoring in the From block. Enter the same date in the To block.

Termination Allowance for an Interrupted Course of Treatment: Enter the date of the last day of treatment in the From block. Enter the same date in the To block.

24B. PLACE OF SERVICE: Enter 12 to show that the items/services were provided at the patient's home.

24C. TYPE OF SERVICE: Enter 15.

24D. PROCEDURES, SERVICES OR SUPPLIES: Enter the appropriate HCPCS code. For a second or third concurrent therapy, enter the appropriate modifier under MODIFIER.

24E. DIAGNOSIS CODE: Leave blank.

Note: The diagnosis code must be entered in block 21. Enter the ICD-9-CM code for the principle diagnosis that corresponds to the service rendered. "V" codes are not acceptable.

24F. CHARGES: Enter the total charge for the items on the detail line.

24G. DAYS OR UNITS: Enter the number of units billed on the detail line as follows:

Drug Therapy Codes: Enter the number of consecutive days shown in 24A.

Nursing Services: Enter the number of consecutive days shown in 24A.

RN Monitoring of Amphotericin B: Enter the number of 15-minute units of monitoring in excess of two hours on the date of service. Calculate the number of units as follows:

Step 1 Total the amount of time that the RN is with the patient to monitor the administration of the drug on the date of service. (Remember, do not include travel time or other time not with the patient.)

Step 2 Subtract the two hours included in the per diem.

Step 3 Divide the remaining number of minutes by 15 to get the number of whole units.

Step 4 Add an additional unit if the remainder is 8 minutes or more.

Example: The RN is with the patient for 3 hours, 47 minutes on 11/15/03 to monitor the administration of Amphotericin B. The first two hours are included in the per diem rate - they may not be billed. Divide the remaining one hour, forty-seven minutes (a total of 107 minutes) by 15. 107 minutes divided by 15 equals 7 units with a remainder of 2. Because the remainder is less than 8, do not add an additional unit. You may bill for 7 units for 11/15/03 under HCPCS code T1002SD.

Termination Allowance: Enter the number of days that the allowance applies, not to exceed seven days.

24H. EPSDT/FAMILY PLANNING: Leave blank.

24I. EMG: Leave blank.

24J. COB: Optional.

24K. RESERVED FOR LOCAL USE: Optional.

Denied Details
Because many of the new codes are dependent on the payment of other codes – for example, nursing services will not be paid if payment has not been made for the related primary therapy – providers must determine what causes a denial before attempting corrective action. The problem with the detail that failed to process must be resolved before any services dependent on payment of that detail will process for payment.

Example: A provider files a claim for a concurrent course of treatment that includes antibiotic therap, pain management therapy, and the nursing services. Antibiotic therapy is the primary therapy for billing purposes with this combination therapy; therefore, if the detail for the antibiotic therapy fails to process for payment, the detail for pain management as the second therapy and detail for the nursing services will deny. The provider must resolve the problem with the billing of the antibiotic therapy before resubmitting a claim for the other services.

Providers should consult the N.C. Medicaid Community Care Manual for additional information about Medicaid HIT coverage.

• N.C. Medicaid Community Care Manual

EDS, 1-800-688-6696 or 919-851-8888

Attention: Optical Providers

HIPAA Code Conversion for the Visual Services Program

To comply with the implementation of national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA), it is necessary to end-date all N.C. Medicaid state-created (local) codes and convert them to national codes. Effective with date of service July 31, 2003, all state-created optical codes will be end-dated. Effective with date of service August 1, 2003, providers must submit national codes when billing for optical services. These changes apply to paper and electronic claim formats. Please continue to use the CMS-1500 claim form (formerly HCFA-1500).

Billing Procedures for Visual Aids and Dispensing Fees
Materials are to be billed at invoice cost and the invoice must be submitted with CMS-1500 form. Dispensing fees are to be billed at the established fee.

Visual Aids

Provider’s Supply of Medicaid Frames/Lenses
(Requires Justification and Prior Approval)

Note: Bill V2799 as one unit only.

Contact Lenses

Note: Bill one contact lens as one unit. Bill a pair of contact lenses as two units.

Subnormal Visual Aids

Dispensing Fees

Spectacle Lenses

Note: Bill one lens as one unit. Bill a pair of lenses as two units.

Frames and Repairs
(to include adjustments)

Contact Lenses

Note: Providers will be notified in future Medicaid bulletins when these codes will be end-dated and replaced with national codes.

Replacement Contact Lenses

Dispensing Fees for Contact Lenses Include K-Readings, Measurements, Fitting, Training, etc.

Telescopic and Microscopic Aids

EDS, 1-800-688-6696 or 919-851-8888

Attention: Personal Care Services (In Private Residences) Providers

Billing and Claim Form Changes for Personal Care Services in Private Residences

Effective with date of service October 1, 2003, providers of Personal Care Services (PCS) must bill on the CMS-1500 claim form using HCPCS code S5125 "Attendant care services; per 15 minutes" for services provided in private residences. Dates of service through September 30, 2003 must be billed on the UB-92 claim form using revenue code 599. The Division of Medical Assistance (DMA) must make these changes to comply with the implementation of the national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA). This article revises the applicable billing instructions listed in the N.C. Medicaid Community Care Manual.

Providers must complete each block in line 24 on the CMS-1500 as follows:

24A. DATE(S) OF SERVICE, From/To: Use a separate detail line for each day that the service is provided. Enter the date of service in the From block. Enter the same date in the To block.

24B. PLACE OF SERVICE: Enter 12 to show that the items/services were provided in the patient's home.

24C. TYPE OF SERVICE: Enter 01.

24D. PROCEDURES, SERVICES OR SUPPLIES: Enter S5125.

24E. DIAGNOSIS CODE: Leave blank.

Note: The diagnosis code must be entered in block 21. Enter the ICD-9-CM code for the principle diagnosis that corresponds to the service rendered. "V" codes are not acceptable.

24F. CHARGES: Enter the total charge for the units for each date of service on the detail line. (The charges are calculated by multiplying the provider agency’s unit rate by the number of units.)

24G. DAYS OR UNITS: Enter the number of 15-minute units billed on the detail line. Refer to Section 6.12.2, Units of Services in the N.C. Medicaid Community Care Manual for instructions on calculating the number of units.

24H. EPSDT/FAMILY PLANNING: Leave blank.

24I. EMG: Leave blank.

24J. COB: Optional.

24K. RESERVED FOR LOCAL USE: Optional.

These changes do not affect coverage policy, related procedures and requirements or the reimbursement rate. Providers should consult the N.C. Medicaid Community Care Manual for additional information about Medicaid PCS coverage in private residences.

CMS-1500 claim form instructions are available in the General Medicaid Billing/Carolina ACCESS Policies and Procedures Guide.

• N.C. Medicaid Community Care Manual

EDS, 1-800-688-6696 or 919-851-8888

Attention: Private Duty Nursing Providers

Billing Changes for Private Duty Nursing

Effective with date of service October 1, 2003, the following changes will be made when requesting approval of and billing for Private Duty Nursing (PDN):

1. The unit of service to use for prior approval and billing will be 15 minutes instead of an hour. The Division of Medical Assistance (DMA) will automatically convert the unit of service to 15-minute units for prior approvals that are in effect as of October 1, 2003. Providers will not have to submit a new prior approval request to convert the units for those patients.
2. The 15-minute maximum allowable reimbursement is $8.84. Providers are reminded to bill their usual and customary charge for the service.
3. Providers will use the CMS-1500 claim form instead of the UB-92 to file claims.
4. Providers will use HCPCS code T1000 "Private duty, independent nursing services – licensed, up to 15 minutes" instead of RC590 to bill for PDN.

Revenue code 590, one-hour unit, and the UB-92 claim form are used for dates of service through September 30, 2003. DMA must make these changes to comply with the implementation of the national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA). This article revises the instructions in the N.C. Medicaid Community Care Manual.

Providers must complete each detail line in block 24 on the CMS-1500 as follows:

24A. DATE(S) OF SERVICE, From/To: Use a separate detail line for each day that the service is provided. Place the date of service in the From block. Enter the same date in the To block.

24B. PLACE OF SERVICE: Enter 12.

24C. TYPE OF SERVICE: Enter 01.

24D. PROCEDURES, SERVICES OR SUPPLIES: Enter T1000.

24E. DIAGNOSIS CODE: Leave blank.

Note: The diagnosis code must be entered in block 21. Enter the ICD-9-CM code for the principle diagnosis that corresponds to the service rendered. "V" codes are not acceptable.

24F. CHARGES: Enter the total charge for the units on the detail line. The charges are the provider agency’s unit rate times the number of units billed on the line.

24G. DAYS OR UNITS: Enter the number of 15-minute units billed on the detail line. Do not enter an amount in excess of the prior approved amount. If less than 15 minutes but more than 8 minutes of care have been provided, a whole unit of service may be billed.

Example: The patient is approved for 34 units (eight hours, 30 minutes) of PDN per day. On 11/2/03, the primary caregiver asks the PDN nurse to leave early so that the caregiver can take the patient for a physician visit. The PDN nurse completes six hours, 35 minutes of care. The provider agency may bill for 26 units (six hours, 30 minutes) of PDN for 11/2/03. The provider may not bill for the additional five minutes.

24H. EPSDT/FAMILY PLANNING: Leave blank.

24I. EMG: Leave blank.

24J. COB: Optional.

24K. RESERVED FOR LOCAL USE: Optional.

These changes do not affect coverage policy, or the related procedures and requirements. Providers should consult the N.C. Medicaid Community Care Manual for additional information about Medicaid PDN coverage.

CMS-1500 claim form instructions are available in the General Medicaid Billing/Carolina ACCESS Policies and Procedures Guide.

• N.C. Medicaid Community Care Manual

EDS, 1-800-688-6696 or 919-851-8888

Checkwrite Schedule

July 15, 2003	August 12, 2003	September 3, 2003
July 22, 2003	August 19, 2003	September 9, 2003
July 31, 2003	August 28, 2003	September 16, 2003

Electronic Cut-Off Schedule

July 11, 2003	August 8, 2003	September 5, 2003
July 18, 2003	August 15, 2003	September 12, 2003
July 25, 2003	August 22, 2003
	August 29, 2003

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.

2003 Checkwrite Schedule